Director, Claims Process Optimization ( Facets Required)

Job Summary:

The Director, Claims Process Optimization leads the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across CareSource claims operations. This position is accountable for identifying where intelligent automation can remove manual effort, building the business case, guiding delivery alongside configuration, information technology, and vendor partners, and proving the result in sustained production performance rather than in pilot metrics.

Essential Functions: Maintain process oversight across assigned claims adjudication and adjustment workflows, monitors the operating budget for the portfolio, manages vendor performance, and leads a team of managers, analysts, and process specialists.

Own the operating performance of assigned claims processes, including inventory levels, aged inventory, throughput, auto-adjudication rate, financial and procedural accuracy, and regulatory turnaround time.

Build and maintain the claims automation and artificial intelligence roadmap, prioritizing use cases by measurable benefit, implementation effort, data readiness, and regulatory risk.

Quantify and defend benefit realization after implementation, comparing production results against the baseline captured before deployment and reporting variances.

Direct end-to-end analysis of assigned claims workflows, using process mapping, time studies, and production data to locate the constraints that drive cost, rework, and delay.

Build the business case for automation and improvement investments, including projected savings, capacity impact, and payback period, then report actual performance against that case.

Track cost per claim and capacity utilization, and use both to inform staffing, sourcing, and automation sequencing decisions.

Develop and monitor the operating budget for assigned functions and technology initiatives.

Direct root cause analysis on recurring defects and drive resolution with upstream owners in configuration, provider data, and enrollment rather than absorbing rework downstream.

Maintain current documented procedures, process controls, and supporting evidence so the operation stays ready for internal audit and for state, federal, and delegated reviews.

Run the performance management cadence, including daily production reviews, weekly operating reviews, and monthly business reviews, so risks surface while there is still time to act on them.

Manage outsourced, offshore, and technology vendors against contracted service levels, quality standards, and delivery commitments.

Participate in vendor selection, statement of work development, and renewal decisions, ensuring service levels, data protection terms, and automation expectations reflect operational reality.

Perform any other job related duties as requested.

• Education and Experience: Bachelor's degree in business, health administration, data analytics, or a related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Seven (7) years of health plan claims or healthcare operations experience is required
• Five (5) years of leadership experience is required
• Competencies, Knowledge and Skills: Practical understanding of automation and artificial intelligence capabilities applicable to claims work
• Working knowledge of claims adjudication platforms, provider reimbursement methodologies, and standard code sets including CPT, HCPCS, ICD-10, and revenue codes
• Strong analytical skills
• Proven change leadership skills
• Strong financial acumen
• Clear written and verbal communication, including the ability to present technical detail and operational risk to executive audiences
• Licensure and Certification: None
• Working Conditions: General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required